Not that many people get excited about the prospect of having a doctor put a scope up their bum, but consider the alternative: 50,000 people die of colorectal cancer each year. If everyone got screened, that number could be cut in half, says Dr. Jordan Karlitz, an associate professor of gastroenterology at Tulane University and a member of the National Colorectal Cancer Roundtable. Tragically, many people (some 28%, or 1 in 3 people, according to the Centers for Disease Control and Prevention) do not get screened—some because they lack access to information and healthcare, and others who know they should get screened and have access but are squeamish about anything poop-related, or fearful that it will be painful or embarrassing.

(According to Dr. Patricia Raymond, a practicing gastroenterologist and assistant professor of clinical internal medicine at Eastern Virginia Medical School in Norfolk, Virginia, men are generally more reluctant than women to get screened, possibly because men are less likely to have had invasive procedures.)

Aren’t There Other Tests?

There are other tests, but because little research has been done comparing how the various forms of screening stack up against each other in terms of finding cancerous or pre-cancerous polyps and preventing death, major organizations including the United States Preventive Services Task Force and the American Cancer Society recommend only that you get screened, leaving the choice of the screening method up to you and your doctor. In their latest recommendations the U.S. Multi-Society Task Force of Colorectal Cancer, a group made up of gastroenterologists, state that colonoscopy is the preferred test for colorectal cancer. They say that when it comes to detecting polyps—in all stages of development—a colonoscopy is the most sensitive and offers a two-for-one deal: it allows a doctor to see polyps and remove them all at once. Plus, if your first one is normal, and you don’t have high risk factors, you don’t need to get another for 10 years.

Advertisement

Doctors also recommend the fecal immunochemical test (FIT), in which small amounts of stool are smeared on cards or collected in tubes and tested for the presence of blood. This test has to be done once a year and might not detect tumors that aren’t bleeding. If you test positive on the FIT, you’ll need to get a colonoscopy.

Less frequently used options include CT colonography, the FIT–fecal DNA test, and flexible sigmoidoscopy. All three of these are less sensitive than a colonoscopy and the FIT and must be done more often (once every five, three, and five to ten years respectively). You might have one of these tests if colonoscopies are not available in your area or you are uninsured (all insurance plans that are ACA compliant are required to follow the Task Force’s recommendations for cancer screening). “People should understand that these less invasive tests are not a way out of a colonoscopy,” says Dr. Durado Brooks, vice president of cancer control interventions at the American Cancer Society. “If those tests are abnormal, you’re going to have to have a colonoscopy.”

Advertisement

Dr. Brooks says it’s also important to know that if you opt to have a test other than a colonoscopy, get positive results, and are then sent to have a colonoscopy, that colonoscopy might be classified as a diagnostic rather than screening test, meaning that you might be responsible for a co-pay or deductible to cover it. This is not the case if the colonoscopy is the first test you get.

If you are colonoscopy-bound, know this: the procedure itself is a breeze, the prep has gotten a lot simpler, and the payoffs enormous. Below, what to expect—and how to prepare—for your first colonoscopy:

What Is a Colonoscopy and Why Get One?

During a colonoscopy, your doctor uses a very thin and flexible scope equipped with a light to inspect the lining of your colon for polyps. Most polyps are benign, but some are capable of becoming cancerous if they are not removed, and others are malignant. If the doctor finds a polyp, it can be immediately removed and sent to a lab for analysis.

Colorectal cancer is really common (it’s the third most common cancer in men and women) but it’s also very preventable. Death rates from colorectal cancer have been dropping in recent years, which the American Cancer Society attributes to increased screening and removal of polyps which, if left in place, might have turned into cancer. It can take as many as 10 to 15 years for a polyp to develop into colorectal cancer, and during this time it’s possible not to have any symptoms that might reveal its existence. As with most cancers, if colorectal cancer is found early, it’s much more likely to be curable.

“Average risk Americans—those without a family history—have a 6% chance of colorectal cancer. That is a huge chance,” says Dr. Raymond. “Just think how excited you would be if you had a 6% chance of winning the Powerball lottery—you’d be excited by the high odds. A colonoscopy with removal of polyps prevents up to 95% of colorectal cancer.”

Who Should Get a Colonoscopy?

The short answer is everyone; it’s a matter of when, not if, you need to take care of business. For starters, if you’re currently experiencing symptoms like a change in bowel habits, or seeing blood in your stool, see your doctor right away—regardless of your age—and inquire about getting a colonoscopy.

Advertisement

If you have a personal history of colorectal cancer or adenomatous polyps (the ones most likely to become cancerous), or a personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease) you should definitely be seeing your doctor on the regular and getting frequent colonoscopies. The same goes for those of us who have a family history (and “family” includes not just parents, grandparents, and siblings, but uncles, aunts, children, and half-siblings)* of colorectal cancer or polyps or a family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome. If this is you, don’t wait until you’re 45 or 50 to get screened. Bring it up with your doctor ASAP. Find more details here on recommendations around these specific risk groups.

If you’re African-American, aren’t having symptoms, and don’t have any of the risk factors above*, starting at age 45, you should get a colonoscopy every 10 years. For reasons that are unclear (but may involve lack of access to and awareness of screenings plus so-called “lifestyle factors” like smoking and obesity), African-Americans tend to be diagnosed with colorectal cancer at younger ages with cancers that are more advanced, and have worse survival rates than other groups in this country.

If you’re not African-American, aren’t having symptoms, and don’t have any other risk factors above*, starting at age 50 you should have a colonoscopy every 10 years.

Advertisement

*When was the last time you called your mom? Or your grandma? Do it. Not just to be kind or assuage your guilt; do it so you can grill them about your family’s health history. It’s so important and not something you want to put off (sorry to bring it up, but you want to have this conversation while they’re still around and have all their marbles).

I’m Way Under 45. Why Should I Think About Colorectal Cancer?

Recent studies have shown that while colorectal cancer rates are going down overall, people in their 20s, 30s, and 40s have been getting diagnosed with colorectal cancer and dying at higher rates than in previous decades. Dr. Jordan Karlitz, an associate professor of gastroenterology at Tulane University and a member of the National Colorectal Cancer Roundtable, says no one is sure why this is happening but that multiple studies hoping to answer this question are currently underway.

Advertisement

“The most important thing you can do is take any symptoms you might be having very seriously and see your physician to discuss the possibility of having a colonoscopy even if you’re younger,” says Dr. Karlitz, who also points out that it’s very important to know your family health history because clusters of certain kinds of cancer in a family could signal an increased risk of getting colorectal cancer at a young age.

When You Make Your Appointment

Different doctors use different types of sedation for a colonoscopy and you should discuss the options with them and decide on the level of sedation that’s right for you. The most common choice is propofol, which is fast-acting and offers a sedation level comparable to general anesthesia without its long recovery time. For most people propofol takes effect within seconds, renders you unaware of what’s going on during the procedure and unable to remember it afterwards. It’s very common to wake up in the recovery area wondering how you got there and when your procedure is going to happen. (Because it’s deeply sedating, you’ll likely encounter an anesthesiologist or sedation team in the procedure room who will monitor you.) Other drugs leave you awake but groggy. Some patients opt to have the procedure wide awake.

Advertisement

Your doctor will give you very specific instructions and you should read them when you get them, because you might need to follow a special diet (to avoid things that are hard to digest and will leave residue in your colon) for the days leading up to the procedure and you might have to pick up prescription preparations (you also might want to pick up some special wipes, if that’s your thing). If you normally take prescription medicines in the mornings, talk with your doctor about how to manage them on the day of your procedure. If anything’s unclear, ask.

Because you’ll be sedated during the procedure, you’ll have to arrange for someone to pick you up afterwards or, depending on the rules of the facility doing the procedure, arrange for a taxi or rideshare to collect you. Some facilities don’t want you going home alone because you might be light-headed. If you think transportation might be a problem, talk to your doctor; this is totally common and most facilities have work-arounds.

Colonoscopy Prep: Not That Bad, Really

Have you ever had serious diarrhea? I’m sorry. The good news is, colonoscopy prep isn’t remotely as bad as that. Yes, it’s yucky, and yes, you will be spending some quality time on the toilet the night before your screening and possibly the morning of, but you’re not sick. You shouldn’t experience painful cramping, nausea, or that feeling that you’re a complete idiot for eating whatever it was that you’ve decided made you sick. (If you share a bathroom, plan accordingly; you will be monopolizing the place for a stretch and you probably will want some privacy.)

The Day Before

Most likely you will be instructed to have only clear liquids the day before the test. This means clear sodas like Sprite, lemon Jell-O, apple juice (not cider) and water. As Dr. Karlitz says, “if you hold it up in glass you should be able to read a newspaper through it. It shouldn’t be opaque.” The clear liquids and the diet modifications and the special drink you’ll be enjoying (more on that below) all work to ensure that your colon is clean and sparkly so that when your doctor peeks inside, they get a really clear picture of what’s going on.

The Night Before

Your doctor might instruct you to drink a prescription liquid to get things started. The good news is that the liquids are generally less icky than they used to be and there is a lot less of it to drink than in years past; some doctors also now use something called “split prep” where you drink half the night before the procedure and half the morning of. The liquids vary and so do the people drinking it; some people find the liquid gross and some people just find it not that great.

Advertisement

Results vary, but typically it takes about an hour of drinking a set amount at specific intervals to finish your ration. In another hour or so you will likely start feeling a strong urge to “evacuate,” as the professionals say. You will spend the next couple of hours evacuating pretty regularly, and eventually you will just be passing clear liquid which is the goal (congratulations!).

And then, we promise, it will stop. You won’t be up all night waiting for it to end, and you won’t be getting up in the middle of the night for a surprise evacuation. If you have followed the doctor’s instructions you will have plenty of time to get to bed at your usual time and have a normal night’s sleep. It’s likely you will be instructed not to drink or eat anything (other than the prep liquid) after midnight. If you are doing the split prep, you will get up in the morning at a set time before the procedure and drink the rest of the liquid but by that point you will know what to expect (plus, you will only have the prep liquid to evacuate) and then it’s off to the procedure.

When You Arrive at the Facility

Your colonoscopy might take place in an ambulatory surgical center, hospital, or the doctor’s office. When you arrive, you’ll likely fill out some paperwork, including consent forms for the sedation medication you’ll be given (you’ll agree to not drive, operate machinery, or sign any documents for the rest of the day following the procedure). You’ll change into a gown and your vitals will be taken; you might answer questions from intake staff, nurses, or an anaesthesiologist (don’t be alarmed—you’re not going to be given general anaesthesia!), be briefed on the procedure and given a chance to ask questions.

Before The Procedure Begins

Along with the doctor, there might be a nurse, attendant, or anaesthesiologist in the procedure room. You might be asked to turn on your side and draw your knees up; a drape will cover you. Through an IV you’ll be given sedating medication.

Advertisement

The procedure takes 30 minutes on average, says Dr. Karlitz but can take up to an hour, depending on whether a polyp (or polyps) are detected and removed. The colonoscope is very thin (about the thickness of a finger) and is equipped with a camera, a light, and a channel through which air is passed, which slightly inflates the colon in order to allow a clearer view of its lining. The colonoscope begins its journey at the far end of the colon and travels its length, during which time the doctor follows what it sees on a large, high-definition TV screen. If polyps are encountered, they are removed via tiny instruments passed up through the scope and sent to a lab for analysis. If there’s bleeding, other tiny tools are passed up through the scope to stanch it. Any bleeding is typically minor, though, and complications from colonoscopies are uncommon. Your blood pressure, heart rate, and respiration are monitored throughout the procedure.

After the Procedure

You might feel sleepy or out of it until the sedation meds wear off; this can happen in a matter of matter of minutes or take up to a couple of hours. If you have arranged for someone to accompany you home, they might be in the recovery room with you as you wake up.

Advertisement

It’s not uncommon to feel a little bloated from the air that was piped into your colon and it’s possible that you’ll pass a little residual gas (sorry, friend who came to pick you up!). Once the doctor ascertains that you’re mentally clear, they will explain to you what they found, how soon you’ll get results, and possibly show you still images taken during the procedure. They’ll explain what’s normal to encounter over the next couple of days (a little bit of blood in your stool if polyps were removed) and what isn’t (pain, fever, serious bleeding). You’ll be given instructions on what to do if you encounter any problems, told how and how soon you’ll get results on any specimens taken; you’ll also be told when to get your next screening.

The doctors will also advise you to take it easy for the rest of the day and you might be offered some juice or crackers. Once you’re rested up, you’ll be ready to get dressed and go out into the world and, most likely get yourself something to eat that isn’t a clear liquid.